4 year outcomes in a prospective evaluation of transcatheter mitral valve-in-valve, valve-in-ring and valve-in-mitral annular calcification: results from the MITRAL trial

Background

The MITRAL Trial (Mitral Implantation of TRAnscatheter vaLves) evaluates the safety and feasibility of balloon-expandable aortic transcatheter heart valves in patients with severe mitral valve disease with mitral annular calcification (MAC), failed surgical rings or failed bioprostheses.

Purpose

We sought to evaluate 4-year outcomes of patients enrolled in the MITRAL trial.

Methods

This is a prospective study that enrolled 91 high surgical risk patients at 13 sites in the U.S. 30 patients underwent Mitral Valve-in-Valve (MViV), 30 Valve-in-Ring (MViR) and 31 Valve-in-MAC (ViMAC). 4-year outcomes of these patients were evaluated in this analysis. Primary endpoints and key serious adverse events including deaths were adjudicated by an independent Clinical Events Committee. Cardiac computed tomography (CT) and echocardiographic images were evaluated by independent CT and Echocardiographic Core Laboratories.

Results

Mean age was 74.3±8.9 years. Most patients undergoing MViV and ViMAC were female (MVIV=63.3%, MViR=36.7% and ViMAC=71%). Mean STS score was 9.2±6.6% (MViV 10.2±6.5%, MViR 8.7±4.7%, ViMAC=8.6±8.2%). All-cause mortality at 4 years was higher for ViMAC and MViR: MViV=6.9% (cardiovascular 3.4%), MViR=48.1% (cardiovascular 18.5%), ViMAC=51.9% (cardiovascular 29.6%), p=0.002 (Figure 1). At 4 years, all survivors had ≤1+ mitral regurgitation and most had none or trace mitral regurgitation (MViV=87.5, MViR=33.3% and ViMAC=100%). Mean mitral valve gradients remained stable (MViV=5.9±2.2 mmHg, MViR= 6.6±5.1 mmHg, ViMAC=5.1±1.0 mmHg), Figure 2. Most survivors experienced significant improvement of symptoms and were in NYHA class I-II at 4-year follow-up (MViV=78.9%, MViR=66.7% and ViMAC=66.7%).

Conclusions

MViV is associated with excellent outcomes at 4 years. MViR and ViMAC were associated with higher mortality at 4 years. However, most survivors in all groups experienced sustained improvement of symptoms and stable THV performance at 4 years. Whether survival bias had an impact on THV performance and improved symptoms at follow-up is not known and deserves further evaluation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Unrestricted Research Grant from Edwards Lifesciences.

Successful management of refractory bleeding in liver failure with tranexamic acid: Case report and literature review

A 50-year-old woman with advanced cirrhosis presented with spontaneous subdural hematoma. She had a worsening clinical course following craniotomy despite administration of multiple blood products. With elevation in D-dimer, persistently low fibrinogen and poor response to factor/fibrinogen replacement therapies, we had a suspicion for uncontrolled fibrinolysis. A literature review was conducted on treatment of hyperfibrinolysis in cirrhosis, finding 4 reports in which antifibrinolytics were used to control bleeding with different outcomes. The dose of tranexamic acid used in our patient was employed from previous experience in trauma patients. We transitioned from intravenous to oral administration based on expected pharmacokinetics. Our patient had a successful outcome with resolution of bleeding.

Utility of the Breast Cancer Index (BCI) in the clinical practice

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Background: Extended endocrine therapy (EET) greater than 5 years in early stage hormone receptor positive (HR+) breast cancer (BC) patients has shown benefit. However, EET is associated with side effects and there is no validated assay to determine which group of patients would derive benefit. Breast Cancer Index (BCI) is a validated bio-marker test that incorporates 2 distinct genomic assays and is prognostic/predictive. The objective of this study is to assess patient characteristics, pathologic features and patient preferences with regards to extending endocrine therapy after reviewing the BCI results. Methods: We performed a retrospective chart review on early stage HR+ BC patients from Jan, 2016 to Jan, 2017 at the University of Vermont Medical Center. We identified 25 cases on whom BCI was submitted. Results: Median age was 68 years. Majority of the patients were stage IA (64%). 56% of the tumors were moderately differentiated. All patients were ER +ve and 12% were HER2+. Median tumor size was 1.4 cm (0.3-4). 76% had poor tolerance to the ET and preferred the test to be sent. In LN-patients, BCI identified 42% as high risk and 52% as low risk for late recurrence and 32% who derive high benefit from EET. In LN+ patients, BCI identified 75% as high risk for late recurrence and 25% as low risk for late recurrence. 40% of the entire group were identified to highly benefit from EET (70% agreed to continue ET and 30% denied due to side effects). Conclusions: BCI is a reasonable test to consider in early stage HR+ BC, especially in patients with poor tolerance to ET. This test might aid in decision making with tolerability/compliance challenges to EET. [Table: see text]

Evolution of definitions and understanding of vascular complications related to transcatheter aortic valve replacement

Vascular complications have emerged as a major clinical challenge during transcatheter aortic valve replacement (TAVR). Recent reports demonstrate that major vascular complications not only predict major bleeding, transfusions, and renal failure, but are also associated with increased mortality. During the early development of TAVR, heterogeneous definitions of vascular complications were used in the literature. However, the Valve Academic Research Consortium has made significant progress in standardizing outcomes definitions in the study of this emerging technology. This has resulted in a rapidly expanding body of high-quality clinical research exploring important outcomes of TAVR, including vascular complications. This review seeks to summarize the literature and to explore the current state of knowledge with respect to the incidence, predictors, clinical impact, and management of vascular complications associated with TAVR.

Paravalvular leak after transcatheter aortic valve replacement

Paravalvular leak (PVL) is a frequent complication of transcatheter aortic valve replacement (TAVR) that occurs at a much higher rate after TAVR than after conventional surgical aortic valve replacement. Recent reports indicating that PVL may be associated with increased late mortality have raised significant concern. However, the heterogeneity of methods for assessing and quantifying PVL, in addition to lack of consistency in the timing of this assessment, complicate the understanding of its true prevalence, severity, and clinical implications. The following review is an effort to consolidate current knowledge in this area in order to better understand the incidence, progression, and clinical impact of post-TAVR PVL, as well as to focus future research efforts on the assessment, prevention, and treatment of this important complication.

Echocardiographic assessment of pressure volume relations in heart failure and valvular heart disease: using imaging to understand physiology

Pressure volume (PV) based analysis, using classic hemodynamic principles, has served as a basis for our understanding of cardiac physiology and disease states for decades. However, PV analysis has been restricted to primarily the basic research setting and for preclinical testing and has not be widely applied in part because of the invasive nature of the procedure and the expertise required to obtain adequate data using the conductance catheter. Development of single beat methodologies that rely on echocardiographic measurements of ventricular volume and Doppler and peripheral estimates of ventricular pressure and timing of the cardiac cycle has enabled broader application of PV analysis. This review explores the physiologic background, basic methodology, and recent and potential future applications of noninvasive PV analysis.

Direct interaction of a vancomycin derivative with bacterial enzymes involved in cell wall biosynthesis

BACKGROUND

The glycopeptide antibiotic vancomycin complexes DAla-DAla termini of bacterial cell walls and peptidoglycan precursors and interferes with enzymes involved in murein biosynthesis. Semisynthetic vancomycins incorporating hydrophobic sugar substituents exhibit efficacy against DAla-DLac-containing vancomycin-resistant enterococci, albeit by an undetermined mechanism. Contrasting models that invoke either cooperative dimerization and membrane anchoring or direct inhibition of bacterial transglycosylases have been proposed to explain the bioactivity of these glycopeptides.

RESULTS

Affinity chromatography has revealed direct interactions between a semisynthetic hydrophobic vancomycin (DCB-PV), and select Escherichia coli membrane proteins, including at least six enzymes involved in peptidoglycan assembly. The N(4)-vancosamine substituent is critical for protein binding. DCB-PV inhibits transglycosylation in permeabilized E. coli, consistent with the observed binding of the PBP-1B transglycosylase-transpeptidase.

CONCLUSIONS

Hydrophobic vancomycins interact directly with a select subset of bacterial membrane proteins, suggesting the existence of discrete protein targets. Transglycosylase inhibition may play a role in the enhanced bioactivity of semisynthetic glycopeptides.

Effects of antiprogestins on the rate of proliferation of breast cancer cells

We have examined the influence of progestins (progesterone, R5020) and antiprogestins (RU486, ZK98299, Org 31710 and Org 31806) on the rate of proliferation of wild type T47D cells cultured in whole fetal bovine serum (FBS) or in single charcoal stripped fetal bovine serum (SSFBS). All of the progesterone antagonists RU486, ZK98299 and two novel antiprogestins Org 31710 and Org 31806 inhibited cell proliferation when cells were cultured in FBS. In contrast, all of the antiprogestins with the exception of ZK98299 enhanced cell growth when cells were cultured in SSFBS. This stimulatory effect of RU486 was observed only at a high concentration of the ligand (1 microM). The effect of R5020, however, was concentration independent. The number of cells in the presence of RU486 was approximately 600% followed by R5020 approximately 400% above control values after a 28 day culturing period. In contrast, when the cells were grown in the presence of medium containing non-stripped whole serum, RU486 inhibited the extent of cell proliferation by 45%. Estradiol (E2) stimulated the rate of proliferation in cells cultured in SSFBS. Similar to when cells were cultured in whole serum, the antiprogestins inhibited cell growth in E2-supplemented SSFBS. Detection of the growth enhancement effects of progesterone receptor (PR) ligands such as RU486 and R5020 on the cells grown in charcoal-stripped medium appear to require the removal of E2 by charcoal stripping of the serum.

Thermal effects of laser stapedectomy in an animal model: CO2 versus KTP

Although use of the laser for stapedectomy has become common in recent years, controversy remains regarding whether the CO2 or visible-spectrum lasers (argon and KTP) are best suited for this operation. The main concern has been the potential for thermal injury to the inner ear with the visible-spectrum lasers attributable to their absorption characteristics. To further investigate this issue, the author performed 20 laser stapedectomies on adult chinchillas. Following placement of a 0.127-mm-diameter copper/constantan thermocouple (sampling at 12 Hz) beneath the footplate on the medial wall of the vestibule via a distant fenestration site, thermal changes with a micromanipulator-based CO2 and fiberoptic KTP system were compared. This was the first live animal model comparison of these two lasers. There was no statistical difference in the mean temperature elevation between the two systems (P = 0.395).

Insulin-like growth factor-1 receptor and its ligand regulate the reentry of adult ventricular myocytes into the cell cycle

To determine whether insulin-like growth factor-1 (IGF-1) stimulation in vitro of ventricular myocytes isolated from infarcted hearts is characterized by the reentry of cells into the cell cycle, the expression and kinase activity of cyclins E, A, and B and DNA synthesis were evaluated 5 days after coronary artery occlusion and 24 and 48 h following the addition of IGF-1. Myocytes surviving an acute myocardial infarction were employed because of their increase in surface insulin-like growth factor-1 receptors (IGF-1R). Western blot analysis documented that IGF-1 resulted in an upregulation of cyclins D1, E, A, and B in viable postinfarcted myocytes. Cyclin E- and A-associated histone H1 kinase activity and cyclin D1-associated retinoblastoma protein-associated kinase activity also increased, but cyclin B kinase activity was not enhanced by IGF-1. These changes in cyclins and kinase activities were characterized by a significant increase in the number of cells labeled by bromodeoxyuridine, from approximately 630/10(6) to nearly 9, 000/10(6) myocytes. This latter value was reduced by more than 50% by antisense oligodeoxynucleotide to IGF-1R mRNA. However, IGF-1 stimulation did not induce nuclear mitotic division and cytokinesis. In conclusion, the growth-promoting effect of IGF-1 on adult myocytes is regulated by the density of IGF-1R, which conditions the activation of the replicatory machinery of the cells. The failure of IGF-1 to enhance cyclin B kinase activity may be responsible for a block in the cell cycle and the inability of myocytes to progress through the M phase and subsequently divide.

A novel 4-cM minimally deleted region on chromosome 11p15.1 associated with high grade nonmucinous epithelial ovarian carcinomas

Prior cytogenetic and restriction fragment length polymorphism studies have demonstrated that allelic deletion of chromosome 11p is common in human invasive epithelial ovarian tumors. To construct a highly detailed deletion map of chromosome 11p, we used 13 polymorphic microsatellite CA repeat primers to identify regions harboring potential tumor suppressor genes. Twenty-three of 48 samples (48%) of invasive epithelial ovarian cancer showed LOH involving at least one locus, consistent with prior studies. None of the five mucinous tumors showed allelic deletion at any of the 13 primers, suggesting that loss of heterozygosity at chromosome 11p may not be involved in the pathogenesis of mucinous ovarian cancer. Two separate minimally deleted regions were identified in nonmucinous ovarian cancer. The first is an 11-cM region on chromosome 11pl5.5-15.3 that extends from D11S2071 to D11S988 and includes the HRAS locus. The second is a novel 4-cM region on 11p15.1, defined by marker D11S1310. Deletion of both regions at 11p15.5-15.3 and 11p15.1 is strongly associated with high grade nonmucinous epithelial ovarian cancer.

Changes in deglutition following tonsillectomy in neurologically impaired children

Tonsillectomy for improvement of dysphagia in children is well recognized, but its effects upon deglutition in the neurologically impaired child have not been described. A review was performed of pre- and post-operative oral-pharyngeal motility (OPM) studies obtained on 15 children (aged 1-10 years; mean 4.6 years) with neurologically-based dysphagia who underwent tonsillectomy for upper airway obstruction (13) or recurrent tonsillitis (2). Each OPM study was rated independently by two trained observers for the presence or absence of 13 features of deglutition. Subjects served as their own control in comparative analysis. There was a mean improvement of 4.33 features of deglutition (mode: 4, range: -1(-)+7) following tonsillectomy. Of 10 children with pre-existing laryngeal penetration or aspiration, two had partial resolution and five had complete resolution following surgery. Post-operatively, two children developed new laryngeal penetration with one also having aspiration. The inter-observer reliability for the OPM study interpretation was 0.90. We conclude that tonsillectomy has a role in the neurologically impaired child with dysphagia, but a pre-operative OPM study is indicated to identify silent aspiration and to aid in necessary counseling for the possibility of a deterioration of deglutition following surgery.

Interaction of newly synthesized antiprogesterone ZK98299 with progesterone receptor from human myometrium

We have undertaken characterization of binding of the newly synthesized progesterone receptor (PR) antagonist ZK98299 in the cellular fractions of human myometrium. Specific [3H]progesterone and [3H]ZK98299 binding was observed in the cytosol and the nuclear fractions, and could be competitively replaced by either of the steroids in their radioinert form. Although PR occupied by both steroids exhibited nuclear uptake, the extent of nuclear binding was lower with [3H]ZK98299-receptor complexes. The binding of both ligands to PR was a function of the duration of incubation and the protein concentration: it was saturable at 3-6 nM steroids with a dissociation constant of approximately 2 nM. However, the number of ZK98299 binding sites (72 fmoles/mg protein) was lower compared to that of progesterone (322 fmoles/mg protein). The relative binding affinity (RBA) of ZK98299 for the nuclear PR was about 33% that of progesterone. The results of our study suggest that ZK98299 binds to PR in the cytosol and the nuclear fractions. The antiprogestin effects of ZK98299 reported in the literature are PR-mediated and may result from suboptimal nuclear binding/retention of antiprogestin-receptor complexes. Since this study did not involve isolation and study of individual PR isoforms, PR-A and PR-B, the present data should be viewed as representing an average of contributions by the two receptor forms.

Taxol and cisplatin inhibit proliferation of T47D human breast cancer cells

We have examined the influence of taxol and cisplatin on the rate and extent of proliferation of T47D cells grown in the presence of 5% fetal bovine serum (FBS). An 8-day exposure of the cells to taxol inhibited the growth completely maintaining the number of cells to the level seen at initial plating. The taxol effect was evident at 10 nM-1 microM concentration and the half maximum inhibition was calculated to be 20 nM taxol. While the cells in the control group taxol-treated group remained at the initial number. Similar observations were made regarding the influence of cisplatin, which caused 80-90% inhibition in the number of the cells. When combined, taxol and cisplatin caused a further inhibition in the proliferation of T47D cells. The results of our studies demonstrate that both taxol and cisplatin, the known antineoplastic agents, block the proliferation of T47D human breast cancer cells effectively and are potentially useful chemotherapeutic agents for the management of breast cancer.

Traumatic rupture of the thoracic aorta. A 20-year review: 1969-1989

Acute traumatic injury of the thoracic aorta is a relatively common injury of deceleration accidents, usually high-speed motor vehicle accidents. The limiting factor to successful hospital management of these victims is early diagnosis and prompt treatment. Between the years 1969 and 1989, 116 patients (87 men and 29 women) were diagnosed with acute traumatic injury of the aorta. The mean age was 38.8 years, and the range was from 11 to 82 years. All patients who presented to the hospital emergency departments were included in the evaluation. The diagnosis of aortic rupture was firmly established by either aortography, surgery, or autopsy. The site of injury in 105 (90.5%) was the aortic isthmus, that is, distal to the origin of the left subclavian artery. In nine patients (7.7%) the injury was in the distal thoracic aorta. Two patients had injuries of the aortic arch. Associated injuries were present in 110 patients (95%); 16 patients (14%) had no external evidence of chest injury. Only 50 patients (43%) had the opportunity for definitive surgical management. The nonsurgical group comprised 66 patients (57%), and all of these died; the cause of death was unsuspected, suspected, or diagnosed after hospital admission from the emergency department. Of the surgical group, 36 patients (72%) survived, whereas 14 patients (28%) died. The surgical management comprised partial cardiopulmonary bypass in 31 patients that included seven deaths, simple aortic cross-clamping in 14 that included six deaths, and nonheparinized bypass in four that included one death. The incidence of paraplegia was 3.2% (one patient) with cardiopulmonary bypass, 28.5% (four patients) with simple aortic cross-clamping and none with nonheparinized bypass.(ABSTRACT TRUNCATED AT 250 WORDS)